In his Guardian column today, Fr. Giles Fraser presents an argument which, has, in various guises, been with us since at least the 1960s: that mental illness, and specifically depression, is the ‘pathologisation of sadness’, and that biochemical treatments for depression are an example of ‘the scientists [being] called in to reinforce generally conservative norms of appropriate behaviour’. This post responds to his article by assessing the ‘anti-psychiatry’ tradition within which it falls, discussing some differences between sadness and depression, examining this difference in the Old Testament, and suggesting a Christian response to mental illness based on the stories of healings and exorcisms performed by Jesus in the Gospels.

Anti-psychiatry, sadness, and depression

Thomas Szasz presented a similar argument from a right-libertarian political perspective, arguing that the major function of psychiatric diagnoses was to provide a justification for individuals failing to take personal responsibility (while also making them more reliant on The State). R. D. Laing argued that the schizophrenic state was one of special insight, which could be ‘worked through’ via methods including regression to childhood (as in the case of Mary Barnes) rather than medication. Michel Foucault considers the advent of ‘mental illness’ as a necessary result of the Enlightenment, a ‘monologue of reason about madness’ which, as Fr. Giles argues, ‘can be just another way of shutting people up’.

All these writers raise an important question about psychiatric therapy – the extent to which medical interventions for mental illness violate the basic sense of free will which underpins social relationships. Given that, as Foucault argues, mental illnesses are described, categorized and treated under the philosophical rubric of the Enlightenment, with all the culture-, class-, and gender-bound elements this implies, does treating mental illness represent the stifling of dissent, the denial of harm done by the dominant politico-cultural narratives by relegating their effects to a spontaneous function of neurochemistry?

The answer, as so often, has to be ‘yes and no’. There is clear evidence, as traced most comprehensively by feminist historians of mental illness including Phyllis Chesler and Elaine Showalter, that categories of mental illness interact with preexisting socio-economic assumptions in order to delegitimize valid critiques of the social order. The category of ‘hysteria’, for example, was often invoked to silence a woman who was, unfortunately, intelligent enough to recognize the limiting influence of patriarchy and raise her voice against it (c.f. political cartoons vs. women’s suffrage). Similarly, it is important that work continues to analyze and critique the contents of and assumptions behind each new iteration of criteria such as the DSM (Diagnostic and Statistical Manual of Mental Illnesses) and ICD (International Classification of Diseases) (see for example the removal of an exception for diagnosing depression following the death of a loved one in the DSM 5) in order to detect instances of ‘mission creep’.

However, just because the concept of mental illness has been used as a tool of political repression doesn’t mean that it doesn’t also describe a recognizable cognitive phenomenon. Anyone who has experience of depression will recognize the feeling of frustration and hopelessness which comes with the realization that, no, they won’t be able to do anything but lie in bed crying today, or the spontaneous, intractable cataloguing of all of one’s past mistakes, from which no attempt at distraction (running, reading, playing video games, meeting friends) can provide an escape. This experience is different in kind to sadness, or even grief, and possesses a specific phenomenological profile, encompassing not just affect (‘I feel sad’), but also cognition (‘That was a stupid thing to do’) and sense of self (‘I am worthless’). The experience of depression goes beyond mere ‘feeling’ to dramatically alter an individual’s whole way of being-in-the-world.

In such circumstances, the effect of antidepressants can be near-miraculous. While the oft-repeated claim that depression is the result of a ‘chemical imbalance’ is at best an oversimplification and at worst a neurobiological fiction, it is true that, by reducing the amount of neurotransmitters such as serotonin, norepinephrine/noradrenaline, and dopamine which are reabsorbed after release, the physiological and psychological symptoms which lead to a diagnosis of depression can be greatly lifted. In these cases, antidepressants, far from ‘silencing’ individuals with psychiatric diagnoses, actually allow them to speak. I’m pretty sure, for example, that I’d not be in a position to be writing a PhD about mental illness and theatre if it wasn’t for the fact that I’m taking venlafaxine. While the precise mechanisms relating to many mental illnesses are still outside the descriptive power of neuroscience, and the placebo effect may be responsible for at least some of the positive impacts of psychiatric medication,[1] it is both inaccurate and potentially harmful to assert that, rather than medication having a positive effect, the effect is a myth leaving the individual disempowered and merely shoring up a failing system.

Sadness and Depression in the Old Testament

Given his line of work, it would not be unreasonable to expect Fr. Giles to be more alive to the cross-cultural nuance of psychological distress. Comparing, for example, the stories of Job and Elijah, provides ample evidence for the fact that situational and pathological sadnesses were distinguishable in a period well before an entity called ‘consumer capitalism’ can be identified. Job is a prosperous man, who is visited with misfortune in order to determine whether his fear of God (properly conceptualized as an amalgam of awe, reverence, love, worship, respect and fear) is merely a result of his prosperity. His response to his misfortune is as follows (Job 1: 20-21):

20 Then Job arose, tore his robe, shaved his head, and fell on the ground and worshipped. 21 He said, ‘Naked I came from my mother’s womb, and naked shall I return there; the Lord gave, and the Lord has taken away; blessed be the name of the Lord.’

The rending of garments, known as keriah, is a specific, culturally sanctioned expression of grief – a way of expressing what Fr. Giles would conceptualize as legitimate unhappiness arising from a recognizable stressor.

Elijah (1 Kings 19:1-15), on the other hand, experiences a very different kind of emotional experience. By all accounts, he has been successful in his line of work (as a prophet). His faith allowed him to demonstrate God’s power in a contest with the priests of Ba’al on Mount Horeb, by praying for fire to spontaneously light a drenched pyre on which was placed a bull as an offering. His prayer had also been answered as he predicted the end of an extended drought. As a result of this, Jezebel, the queen, is threatening to have him killed, which is a potential stressor, but could also be seen as being an occupational hazard of being an Old Testament prophet. Within the narrative, Elijah’s emotional response comes out of the blue, and has much in common with the symptom cluster we now call depression – he is physically exhausted, convinced of his own status as a failure despite evidence to the contrary, and desires death:

4 But he himself went a day’s journey into the wilderness, and came and sat down under a solitary broom tree. He asked that he might die: ‘It is enough; now, O Lord, take away my life, for I am no better than my ancestors.’ 5 Then he lay down under the broom tree and fell asleep.

God’s response to this state is to provide food, water, and encouragement from an angel, before revealing Himself to Elijah in a still, small voice. This is treatment beyond ‘doing a bit more exercise or being more sociable’ as prescribed by Fr. Giles – it is rather a wide-ranging intervention taking into account the physical (sleeping, eating, walking), psychological (emotional, interpersonal support from the angel), and spiritual (food from heaven, an encounter with the divine) aspects of Elijah’s experience. I am not here equating SSRIs with an experience of God, but rather suggesting that an intervention beyond mere political, social, or physical change is necessary in cases of depression, because depression is different in kind from sadness.

The New Testament and Treating Mental Illness

It is a commonplace to note that those described as ‘demoniacs’ in both Old and New Testaments are likely experiencing similar conditions to those we would now characterize as mental illnesses. Before we congratulate ourselves on how much more enlightened we are now we conceptualize these phenomena as treatable illnesses, it’s worth dwelling on just how familiar the Gerasene demoniac in Mark 5 is to any of us who live or work in large cities, and have to pass through those intermediate zones which serve as meeting places for increasing numbers of homeless people:

5 They came to the other side of the lake, to the country of the Gerasenes. 2 And when he had stepped out of the boat, immediately a man out of the tombs with an unclean spirit met him. 3 He lived among the tombs; and no one could restrain him any more, even with a chain; 4 for he had often been restrained with shackles and chains, but the chains he wrenched apart, and the shackles he broke in pieces; and no one had the strength to subdue him. 5 Night and day among the tombs and on the mountains he was always howling and bruising himself with stones.

Leave aside the shackles, or think of them as the limited attempts of family and friends to help a mentally-ill person while experiencing socio-economic difficulties of their own, and this could be a picture of any homeless person down on their luck, moaning in the doorway of a boarded up shop. The experience of mental distress has led to the ties which kept this man within the community being severed. The imagery of broken chains here takes on another metaphorical aspect, making clear the importance of social connections to an individual’s sense of self.

Jesus’s response to the Gerasene demoniac fits into a similar pattern to his other healings, and involves three parts – the transgression of social expectation by interacting with an individual who fell outside social structures, the healing of the illness, and the reintegration of the individual within his or her social milieu. In the New Testament, it is clear that there are both social and physical aspects to illness, and especially to mental distress, and the two cannot be distinguished or treated separately. As with Elijah, the demoniac is treated for the physical elements of his condition, but this also leads to social change. While, in the story of Elijah, this involved the local issue of driving out or killing the prophets of Ba’al, the message in the passage from Mark is significantly more far-reaching.

It is clear from the fact that there are swineherds at all that the story takes place in a non-Jewish area, and as Greg Carey points out (http://www.huffingtonpost.com/greg-carey/mark-5-1-20-exorcism-and-community_b_1628605.html) the driving of a demon called Legion into a herd of pigs which then drowns contains a powerfully anti-Roman message for Jews in occupied Judea. However, the key here is just how transformative (and divisive) Jesus’s exorcisms could be: on seeing what had happened, the locals ‘began to beg Jesus to leave their neighbourhood’ (Mk 5:17), while the demoniac himself, having been reunited with his friends, also finds a renewed sense of purpose, proclaiming the things Jesus had done (as Dominic Crossan has argued, there is a good chance that this was a subversive political message).

Conclusion

Fr. Giles, in pointing to the socio-political contexts for mental illness, highlights an important element of such conditions – the extent to which they both cause and are caused by disadvantageous socio-economic phenomena. However, by leaving the whole blame for this at the feet of antidepressants and Big Pharma, he exacerbates the isolation of those experiencing depression. Whether we’re Christian or not, the narratives discussed above suggest that mental illness is a feature of human culture in all time-periods, and that it can best be treated in a holistic manner – by reaching out to those who are suffering, even and especially when this means going against the conventions of a culture which encourages us to insulate ourselves from any experience of empathy, by ensuring access to the best medical treatment available, whether that’s spiritual, biomedical, or both, and by making the effort to continue to build a community and society within which those experiencing mental illness are integrated, valued, and supported.

As both Foucault and the story of the Geresene demoniac make clear, this integration requires a radical challenge to the social conditions which simultaneously exacerbate and downplay mental illness. The political challenge which Fr. Giles desires will come, not from the elimination of psychiatric drugs from society, but by their judicious use (always guarding against mission-creep and over-diagnosis) and the fostering of support structures which ensure those experiencing depression are supported, rather than being told that they are ‘just’ sad, and would get better if they went for a run.

[1] This is unsurprising, since the placebo effect itself is under-researched, and points to the sheer complexity of brain function – taking a placebo is not, as is commonly supposed, identical to taking nothing, since the very act of swallowing a pill will have an effect on brain function which would not be present in the absence of any stimulus at all.

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A very interesting piece. I’ve suffered chronic depression on and off for 26 years now, and believed for the first 5 that it was somehow my fault and that this was the way I was “meant” to be.

I refused to take antidepressants until 1993, at which point I realised that what was wrong was precisely “an imbalance of chemicals”. After a year of the medicine I was a “normal” person for the first time in a very long time.

Talking therapy (CBT and the like) has never helped me, but now I have an antidepressant that works, as long as I take it I don’t have depression.

Is that placebo? I don’t know and I don’t care. What it is is no depression.